Increasing Mothers' Confidence and Ability by Creating Opportunities for Parent Empowerment (COPE): A Randomized, Controlled Trial.

Objectives
Premature neonates are at great risk for cerebral palsy, developmental delays, hearing problems and visual impairments. Interventions to reduce the morbidities and adverse health outcomes in these neonates and improve parent-infant interaction are highly important. This study was conducted to determine the effect of the Creating Opportunities for Parent Empowerment (COPE) program on the perceived maternal parenting self-efficacy of premature parents.


Materials & Methods
This was a randomized controlled trial with equal randomization (1:1:1 for 3 groups) and parallel group design. Forty-five preterm neonates were randomly allocated to treatment (n=15), supervision (n=15) and control (n=15) groups. COPE program was provided in the form of a 4-phase educational-behavioral intervention to the treatment and supervision groups. The primary outcome was parental self-efficacy, which was assessed by the Perceived Maternal Parenting Self-Efficacy inventory. All the measurements were performed pre- and post-completion with the valid equipment and by blind assessors.


Results
COPE mothers reported significantly stronger beliefs regarding their parental role and have more confidence to their ability in caring of neonates compared with control mothers (P-value <0.001).


Conclusion
An educational-behavioral intervention would strengthen mothers' belief in themselves and knowledge about their neonates and would enhance premature mothers' ability to care for their neonates as well as parent-infant interaction.


Introduction
The birth of a healthy and normal neonate is a celebrated event with happiness for parents, but this is different when a neonate is born prematurely and parents face an unexpected event that involves many challenges (1,2). Parents experience high levels of stress as a result of the preterm birth, diagnosis and hospitalization of neonates that is characterized by sense of fear, guilt, sadness, hostility, irritability, grief, helplessness and loss of confidence (3).
Parents' challenges revolve around issues such as learning to care for the newborn, obtaining information about the neonate, getting to know the baby and dealing with one's own expectations as a parent (4). A review of the available literature demonstrated that parents usually feel incompetent in caring for their neonate after her/his discharge from the neonatal intensive care unit (NICU).
Indeed, self-efficacy, that is parents' perception of themselves as a capable and effective person in assuming parental role (5), is at low level, indicating the importance of training in this population group (6).
There is considerable scientific evidence supporting the significance and necessity of increasing self-efficacy in parents (7), because the degree of self-efficacy is effective in the quality of the care provided by parents as well as the degree of parents' satisfaction with their parenting experience (8). Boosting parents' self-efficacy is important in coping with stress in NICU (9).
Also, perceived competence in the parenting role is directly associated with emotional and parental behaviors, the quality of newborn care and infant's future developmental outcomes (7,10).
Premature parents need to feel efficacious in their parenting role, and parents' practical training and strategies for increasing parents and families' involvement in neonatal care (work book) have important consequences for parent and infant development (11).
Creating Opportunities for Parent Empowerment (COPE) is an educational-behavioral intervention designed based on the presumption that providing parental supportive interventions benefits parents, neonates and families in general (12)(13)(14). A review of the literature revealed that COPE can lower the stress level through increasing parents' knowledge and modifying their beliefs about their preterm neonate (15,16).
Most studies on the efficacy of COPE conducted in different regions of the United States are mainly focused on the mental (i.e., anxiety, depression, negative emotion, and participation in caring) and physical health of parents and their infants (weight gain) (16). Also, there is strong evidence that parent training enhances maternal self-efficacy and empowers mothers for breastfeeding (17,18).
However, there is a gap in the literature concerning how parents' self-efficacy is associated with caring for a preterm infant at home, especially during the first weeks and months after hospital discharge.
The purpose of this study was to evaluate the effect of the COPE program on the perceived maternal parenting self-efficacy (PMP-SE) of premature parents.

Materials & Methods
This was a double-blind, randomized, controlled Sample size was calculated with an α-value of 5% and power of 80%. The analysis accounted for a 20% attrition rate. Fifteen neonates per group were needed to detect clinically worthwhile effects.
After obtaining free and informed consent, neonate randomization was performed using a randomized block design, and the neonates were randomly assigned to the supervision (n=15), treatment (n=15) and control (n=15) groups. After gathering the clinical data, mothers were asked to rate their perceptions about their ability to effectively and successfully assume their caring role as a mother.
PMP-SE was measured using the 20-item Efficacy subscale of the Parenting Sense of Competence scale (17). Items were rated on a 4-point Likert scale ranging from "strongly agree" to "strongly Daily strict implementation of the program was followed by the therapist in the supervision group; the therapist also provided daily comments and reviews. Follow-up assessments were completed one month after discharge by the same person, who was unaware of the group allocations ( Figure 1). The assessor was a master of Occupational Therapy who was expert in the field of pediatric family-centered occupational therapy with four years of experience in neonatal therapy.
The data were analyzed using SPSS. All the values were tabulated as averages (mean) with standard deviation (SD). For all the analyses, the significance level was set at 0.05.

Results
The mean gestational age of the premature infants 28-34 weeks). As shown in Table 1, neonates in all the three groups were matched for all the parameters (i.e., gestational age, birth weight, birth length, head circumference at birth, Apgar scores [1 and 5 min], and prematurity), and there were no significant differences between them at baseline.
According to the results (Table 2), the mean PMP S-E scores of the mothers in the treatment and supervision groups were higher than in the control group, and there was a significant difference between the three groups (P = 0.000).